2.0 Analysis 2.1 Meteorological Conditions Meteorological conditions were conducive to the accumulation of ice on the aircraft when in cloud, and the investigation revealed that ice had indeed accumulated on the aircraft. Even though the co-pilot saw an accumulation of ice on an unheated part of the windshield, the wings were not visually checked by the crew and the de-icer boots were not used. 2.2 The Approach, Stall, and Recovery Attempt The flight crew of the aircraft were qualified on type and all aircraft systems were functioning normally. At Umiujaq, the winds were from 260M at 23 knots while the aircraft was on the approach. The aircraft had a strong tail wind component on the right base leg for runway 21. In these conditions, a turn onto the final approach must be steeper if it is initiated with reference to a fixed point. In addition, the aircraft was flying toward terrain that rose steadily to 650 feet, and the pilot-in-command could not afford to go beyond the final approach track. Executing a constant-altitude turn with 35 degrees of bank would increase the stalling speed of the aircraft from 77 knots to 85 knots. To execute a steep turn at constant altitude, the pilot must pull back on the elevator to maintain altitude, which the pilot did. However, the symmetrical coating of ice on the pneumatic de-icer and the increased angle of bank led to a breakup of the airflow over the surface of the wings and the aircraft stalled. The aircraft was reacting as if it were behind the power/speed curve after the pilot recovered from the stall. Despite the indicated airspeed of 93 knots and maximum power being applied, the aircraft did not climb. Given the rising terrain and the tail-wind component, there was insufficient altitude for the pilot to lower the nose of the aircraft to accelerate. 2.3 NOTAMs The crew was not aware and was not informed that the Umiujaq runway 03/21 was closed. The crew members were not advised of the situation by the air service dispatcher, the FSS, or the CARS. 2.4 Pilot Decision Making The weather for Umiujaq for the period preceding and during the approach was indicating that the ceiling was about 100 feet overcast and that the visibility was reduced to about one mile in light freezing drizzle and light snow. Although the weather observation at Umiujaq was indicating a low ceiling and reduced visibility, the pilots reported the ceiling at Umiujaq during the approach to be 700 feet. They decided to continue with the approach to Umiujaq knowing that they had a suitable alternate airport. All destination points north of Umiujaq had a ceiling greater than 1,300 feet and a minimum visibility of two miles. The weather conditions north of Umiujaq were considered to be suitable for the flight, and the approach into Umiujaq was conducted in accordance with VFR regulations. However, flying a VFR approach in weather conditions of low ceilings and poor visibility produced by light freezing drizzle and light snow showers can be dangerous. Although GPS was used as a supplement to visual navigation during this flight, it is concluded that the use of GPS was not a factor in this occurrence. 2.5 VFR/IFR Flight in Uncontrolled Airspace The rules governing IFR flights in uncontrolled airspace are subject to interpretation with respect to transitioning from IFR to VFR conditions. Article 553 of the Air Regulations contains an exception to the rule that an aircraft must maintain 1,000 feet above the highest obstacle located within a horizontal radius of five miles from the estimated position of the aircraft in flight. The exemption specified is: Except when taking off and landing. Furthermore, article 553 does not specifically address whether visual contact has to be established prior to a descent below 1,000 feet. A descent below 1,000 feet in uncontrolled airspace while in IFR conditions for the purpose of landing is interpreted differently by different Transport Canada personnel. The different opinions also indicate the need to clarify Air Regulation 553. During the approach into Umiujaq, the pilots began to see the ground at 700 feet and obtained sufficient forward visibility to transition from IFR to VFR. The pilots continued the approach to Umiujaq under VFR conditions. The aircraft was clear of cloud and the crew had at least one mile flight visibility. 3.0 Conclusions 3.1 Findings All aircraft systems were functioning normally. A layer of ice covered the pneumatic de-icer in a symmetrical pattern. On final, the pilot made a steep turn of at least 35 degrees, and the aircraft stalled at an altitude from which the pilot was unable to recover. Runway 03/21 at Umiujaq was closed under a NOTAM but the crew members were not aware of the situation. There was an insufficient exchange of information between the air service dispatcher, the FSS, the CARS, and the crew members. The crew decided to continue the visual approach into Umiujaq despite the weather conditions reported. Regulations with regard to descending below 1,000 feet in uncontrolled airspace while in IFR conditions, for the purpose of landing, are interpreted differently by different Transport Canada personnel. 3.2 Causes The stalling speed of the aircraft increased due to ice on the leading edge of the wings and because the pilot made a steep turn; the aircraft stalled at an altitude from which the pilot was unable to recover. A contributing factor was the crew's decision to continue the visual approach into Umiujaq despite the weather conditions reported. 4.0 Safety Action 4.1 Action Required 4.1.1 Obstacle Clearance Altitudes During this investigation, it became evident that Article 553 of the Air Regulations was being interpreted in a way such that its application with respect to operations in uncontrolled airspace was questionable. The regulation, when used as a reference for the flight conditions required for the transition from IFR flight to VFR flight in uncontrolled airspace, appears to have been ambiguous to such an extent that the Transport Canada (TC) Quebec regional office had an interpretation substantially different from that of TC's head office in Ottawa. The flight procedure that brings into question the intent of the regulation is an en route IFR descent in instrument meteorological conditions (IMC) to conduct a VFR landing. Air Regulation 553 requires that aircraft in IFR flight be flown at an altitude 1,000 feet above the highest obstacle within 5 miles of the estimated position of the aircraft, except when taking off or landing3. The descent procedure used by the aircrew in this occurrence, and interpreted by the TC regional office as being acceptable, could eliminate this safety margin. Using a line of thinking consistent with this interpretation, a crew could descend an aircraft in IMC, without being on an approved instrument approach, to an altitude where visual meteorological conditions (VMC) were anticipated, as long as the descent was considered to be for the purpose of landing. The Board and TC's head office both believe that this was not the intent of the regulation. The new Canadian Aviation Regulations (CARs) (recently announced in the Canada Gazette) contain a detailed section on minimum altitudes to ensure obstacle clearance in IFR flight; however, the CARs are no clearer than the Air Regulations as to what differentiates the en route and/or approach phase of a flight from the landing phase. Nevertheless, until the CARs are in effect, aircrew are still required to fly in accordance with the existing Article 553; therefore, some aircrew may still believe that a descent is permissible to any altitude while attempting to transition to a VFR landing. Moreover, given the increasingly widespread use of GPS for navigating in remote areas and considering GPS' reputation for accuracy, aircrew may be more likely than ever to question the need for the 1,000-foot safety buffer. The Board is concerned that regulatory officials and the operator of a fleet of state aircraft apparently did not question the appropriateness of a procedure that put aircraft, crew, and passengers at an increased level of risk. Therefore, the Board recommends that: The Department of Transport advise the aviation community, including Transport Canada regional staff, of the correct interpretation of Air Regulation Article 553; and The Department of Transport clarify the wording of the CARs with respect to descents for landing in uncontrolled airspace to ensure that the intended level of safety is not jeopardized through misinterpretation. 4.1.2 State-Owned Aircraft In Canada, several departments and agencies of the federal and provincial governments operate fleets of aircraft. These fleets vary in size from just a few aircraft to over 100 aircraft, often with a mixture of aircraft types in any one fleet. The aircraft are frequently used to transport passengers, albeit not in a commercial capacity. The state aircraft generally operate under Air Navigation Order (ANO) I, No. 2, which regulates the transport of passengers in private aircraft. Private aircraft in this context include state and corporate aircraft. Thus, a private aircraft with a passenger-carrying capacity of only a few passengers and state/corporate aircraft with significant passenger-carrying capacity (often significantly greater than that of the accident aircraft type) are treated in a similar manner from a regulatory perspective. The Fonds du Service Arien Gouvernemental is classified as a state-owned operation and was operating under ANO I, No. 2. Commercial operations are generally conducted in accordance with ANO VII, No. 2 (large aircraft), and ANO VII, No. 3 (small aircraft). The aircraft type involved in this accident would be operated under ANO VII, No. 2, in a commercial operation. There are significant differences between ANO I, No. 2, operations and ANO VII (particularly ANO VII, No. 2) operations in the areas of the requirement for an operating certificate, operational requirements, crew training and qualifications, and regulatory overview. In the late 1980s, the predecessor to the TSB, the Canadian Aviation Safety Board (CASB), became concerned about the number of occurrences involving another operator of a large fleet of state aircraft, the RCMP. It was noted at that time that a number of the practices and procedures meant to enhance safety in the commercial aviation sector were absent in the day-to-day operation of that fleet. The CASB suggested that the operator request an independent safety survey to assist in identifying shortcomings in the operation. A safety survey was subsequently done by TC and corrective measures were taken. Some of these measures were in excess of ANO I, No. 2, requirements and more in line with ANO VII requirements. The number of significant occurrences involving RCMP aircraft has reduced considerably since 1990. Following this accident, and with the concurrence of Service Arien, Transport Canada initiated a post-accident safety survey of the organization. As a result of this survey, changes were made to the organization's managerial staff. The TSB was unable to determine what other changes, if any, resulted from this survey. In providing its regulatory overview of commercial operators, Transport Canada uses risk management indicators to identify those carriers possibly requiring extra surveillance and audit. However, operators of state aircraft do not come under the same regulatory scrutiny; thus, indicators of increasing risk are less likely to be detected. The operation of TC's own fleet of aircraft is voluntarily subjected to the requirements of an operating certificate similar to that of commercial carriers. The recently announced CARs will require state and private operators of large or turbine-powered, pressurized passenger aircraft to adhere to more demanding safety standards. However, these standards are still not equivalent to those applicable to commercial air carriers. It is recognized that the operations in which state aircraft are often engaged are unique, and that, for the most part, they do not involve the travelling public. Yet, when passengers are regularly carried on state aircraft, it is reasonable for these passengers to expect that the aircraft and aircrew involved in state operations are subject to the same regulatory requirements as commercial carriers. The Board believes, therefore, that state operations would benefit from the increased standards and regulatory overview applicable to commercial operations. Therefore, the Board recommends that: The Department of Transport require that the operators of state aircraft be subject to regulatory overview, as practicable, equivalent to that of similar commercial operations.